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Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments

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This practice review focuses on the challenges of conducting sensitive and accurate assessments of the relative risk for suicide attempts and completed suicides. Suicide and suicide attempts are a frequently encountered clinical crisis, and the assessment, management, and treatment of suicidal patients is one of the most stressful tasks for clinicians. An array of risk factors, warning signs, and protective factors associated with suicide risk are reviewed; however, we are not yet in possession of evidence-based diagnostic tests that can accurately predict suicide risk on an individual level without also creating an inordinate number of false-positive predictions. Given the current limitations of assessment strategies, clinicians are advised to keep in mind that patients contemplating suicide are under enormous psychological distress, requiring sensitive and thoughtful engagement during the assessment process. An overarching goal of these assessments should be conducted within the therapeutic frame, in which efforts are made to enhance the therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. Within this treatment heuristic, the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) is recommended as a pragmatic multidimensional assessment protocol incorporating the best known risk and protective factors.
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PRACTICE REVIEW
Suicide Risk Assessment in Clinical Practice:
Pragmatic Guidelines for Imperfect Assessments
James Christopher Fowler
Baylor College of Medicine
This practice review focuses on the challenges of conducting sensitive and accurate assessments of the
relative risk for suicide attempts and completed suicides. Suicide and suicide attempts are a frequently
encountered clinical crisis, and the assessment, management, and treatment of suicidal patients is one of
the most stressful tasks for clinicians. An array of risk factors, warning signs, and protective factors
associated with suicide risk are reviewed; however, we are not yet in possession of evidence-based
diagnostic tests that can accurately predict suicide risk on an individual level without also creating an
inordinate number of false-positive predictions. Given the current limitations of assessment strategies,
clinicians are advised to keep in mind that patients contemplating suicide are under enormous psycho-
logical distress, requiring sensitive and thoughtful engagement during the assessment process. An
overarching goal of these assessments should be conducted within the therapeutic frame, in which efforts
are made to enhance the therapeutic alliance by negotiating a collaborative approach to assessing risk and
understanding why thoughts of suicide are so compelling. Within this treatment heuristic, the Suicide
Assessment Five-step Evaluation and Triage (SAFE-T) is recommended as a pragmatic multidimensional
assessment protocol incorporating the best known risk and protective factors.
Keywords: suicide assessment, risk factors, alliance
Psychotherapists have much to worry about: Turf battles over
medication prescription privileges, third party reimbursement, and
the ongoing quest for mental health parity. Closer to the consulting
room, we worry about patient’s psychological well-being, im-
provement, and safety—of greatest concern is their short and
long-term risk for suicidal behavior and death. Clinicians have
reason for concern: As death rates decline for many medical
conditions, suicide rates have risen approximately 60% over the
last 45 years, with yearly estimates of 1 million suicides worldwide
(World Health Organization, 2005). In the United States more than
32,000 suicides occurred annually—Suicide is the second leading
cause of death among 25 to 34 year olds, and the third leading cause
of death for people between the ages of 15 and 24 (Centers for
Disease Control, 2007). Suicide attempts are 10 to 40 times greater
than completed suicides, with US estimates nearing 650,000 per year
(Goldsmith, Pellmar, Kleinman, & Bunney, 2002).
Suicide and suicide attempts are a frequently encountered clin-
ical crisis, and the assessment, management, and treatment of
suicidal patients is one of the most stressful tasks for clinicians
(Jobes, 1995). According to survey data, 28% of psychologists and
62% of psychiatrists reported experienced the loss of a patient to
suicide, most frequently in outpatient settings (Chemtob, Bauer,
Hamada, Pelowski, & Muraoka, 1989). The stress and anxiety
associated with treating suicidal patients can, at times, lead clini-
cians to lose sight of the primary objective of psychotherapy
(namely the relief of suffering through greater self-understanding
and improvement in social functioning). Powerful emotional reac-
tions to a suicidal patient can fuel a pattern of defensive behavioral
management that runs the risk of eclipsing the patients suffering,
leading to subtle and overt power struggles. In some cases, a
pattern of chronic crisis management can emerge in which the
clinician adopts a role of a constant savior (Hendin, 1991). Al-
though it is first and foremost necessary to protect the life of the
patient, clinicians must guard against the treatment devolving into
chronic crisis management in which the mutually agreed upon
purpose of the treatment is inadvertently jettisoned. Therefore, the
overarching goal of any assessment of suicide risk should be
conducted within a therapeutic frame in which collaboration and
negotiation of role responsibilities are clearly articulated (Plakun,
1994). At the same time clinicians must work to enhance the
therapeutic alliance by negotiating a collaborative approach to
understanding why thoughts of suicide are so compelling (Jobes,
Louma, Jacoby & Mann, 1998; Jobes, 2011).
The scope, breadth, and volume of suicide research precludes an
exhaustive review of the literature, and any attempt to do so here
would certainly do injustice to the field of suicidology, and subvert
the purpose of this article—those interested in a deeper examina-
tion may find the reference list and a list of hyperlinks (Table 1)
useful. This practice review will focus on three elements: (1)
Challenges facing clinicians assessing risk for adult patients, (2)
An overview of the best predictors of suicide risk, and (3) Prag-
matic recommendations for ongoing risk assessment that places a
Correspondence concerning this article should be addressed to J. Chris-
topher Fowler, PhD, Menninger Department of Psychiatry and Behavioral
Sciences Baylor College of Medicine, 2801 Gessner Drive, Houston, TX
77080. E-mail: cfowler@menninger.edu
Psychotherapy © 2012 American Psychological Association
2012, Vol. 49, No. 1, 81–90 0033-3204/12/$12.00 DOI: 10.1037/a0026148
81
premium on maintaining a collaborative therapeutic frame, attend-
ing to the therapeutic alliance as well as alliance ruptures, and
maintaining an active curiosity regarding the triggers for the sui-
cidal crisis.
Challenges to Suicide Assessment
Effectively assessing suicide risk is dependent on the availabil-
ity of sensitive and specific measures of long-term risk factors,
short-term warning signs, and an appreciation for the complexity
and variability of suicide risk over time. Unlike many diagnostic
procedures assessing relatively stable phenomena, we do not yet
possess a single test, or panel of tests that accurately identifies the
emergence of a suicide crisis. Among the many reason is that
suicide risk is fluid, highly state-dependent, and variable over time
(Rudd, 2006). It should not be a terrible shock, then, to realize that
most of our research efforts to diagnose risk for suicide and suicide
attempts fall short. Historically, research demonstrates statistical
associations among various risk factors aggregated across large
groups of individuals; however, translating elevated risk to the
single individual falters because specific predictors are found
among many individuals who are not suicidal (resulting in high
false-positive prediction).
Thus, despite decades of research, accurate prediction of suicide
and suicide attempts remains elusive. The American Psychiatric
Association (APA) Guidelines on Suicidal Behavior (APA, 2003)
concluded that predicting suicide appears impossible in large part
due to the rarity of suicide, even among high-risk individuals such
as psychiatric inpatients. Beyond statistical challenges posed by
low base rates, longitudinal prediction using relatively distal vari-
ables such as psychiatric diagnoses, demographics, and self-
reported psychological states consistently yield high false-positive
prediction rates, limiting their predictive value (Goldsmith et al.,
2002; Rudd et al., 2006; Oquendo, Halberstam, & Mann, 2003).
Complicating the assessment strategy is the fact that most studies
assess single risk factors, leaving clinicians and expert panels to
estimate how risk factors interact to influence outcomes.
While prediction appears unlikely at this stage, clinicians are
nonetheless responsible for assessing suicide risk, and for provid-
ing treatment to decrease risk (APA, 2003). Modifiable risk factors
include the short-term safety of patients, and treating psychiatric
symptoms/disorders using evidence-based treatments. Among the
hundreds of interventions for suicidality, the following treatments
appear particularly effective in randomized clinical control trials:
lithium prophylaxis for mood disorders (Baldessarini et al., 2006),
clozapine for psychotic disorders (Glick et al., 2004; Meltzer et al.,
2003), psychosocial treatments for suicidal patients with border-
line personality disorder (Bateman & Fonagy, 2008; Clarkin,
Levy, Lenzenweger, & Kernberg, 2007; Doering et al., 2010; Levy
et al., 2006; Linehan et al., 2006), and outreach via communicating
caring and concern remotely (Motto & Bostrom, 2001; Fleish-
mann, Bertolote, Wasserman et al., 2008) or in-home psychody-
namic consultations (Guthrie et al., 2001).
The aforementioned psychosocial interventions demonstrate the
efficacy of developing and maintaining a caring interpersonal
contact (even if by letter or phone) in reducing suicide risk. As will
be discussed in a later section, the quality of social relationships
can either serve as a protective or risk factor, and it stands to
reason that the quality of a collaborative therapeutic relationship,
the clinician’s ongoing care and interest in the patient, and efforts
to repair ruptures in the alliance may exert a powerful influence on
the patient’s degree of hope for the future, and the degree to which
suicidal related behaviors decrease. Recent open trials of a suicide
prevention strategy based on collaboration, therapeutic alliance,
and enhancing social contacts reduced rates of suicidality (Ellis,
Green, Allen, Jobes, & Nadorff, in press; Jobes, Wong, Conrad,
Drozd, & Neal-Walden, 2005; Jobes, Kahn-Greene, Greene, &
Goeke-Morey, 2009). It is therefore recommended that clinicians
work to enhance the therapeutic alliance, consider recent ruptures
that may contribute to suicidal ideation, and work to develop a
collaborative approach to understanding the underlying causes for
suicidal ideation (Jobes, 2011). With this practice heuristic in
mind, the brief review of suicide research will touch on the
evidence for those risk and protective factors with the strongest
evidence base, then turn to a pragmatic and clinically sensitive
approach to discussing suicide risk with patients.
Static Risk Factors for Suicide and Suicide Attempts
Suicide research began, and for the most part continues to focus
on single, static risk factors such as demographic factors, psychi-
atric diagnoses, past high-risk behaviors, and more recently, ge-
Table 1
Selected Resources for Suicide Assessment and Suicide Facts
American Association of Suicidology http://www.suicidology.org/web/guest/home
American Psychiatric Association Practice Guidelines for the
Assessment and Treatment of Patients with Suicidal
Behaviors
http://www.psychiatryonline.com/pracGuide/PracticePDFs/
SuicidalBehavior_Inactivated_04–16–09.pdf
American Foundation for Suicide Prevention (AFSP) http://www.afsp.org/
International Association for Suicide Prevention:
IASP Guidelines for suicide prevention www.med.uio.no/iasp/english/guidelines.html
National Suicide Prevention Resource Center http://www.edc.org/projects/national_suicide_prevention_resource_center
Risk Management Foundation Harvard Medical Institutions http://www.rmf.harvard.edu/files/documents/suicideAs.pdf
Substance Abuse and Mental Health Services Administration
(SAMHSA) Suicide Assessment Five-Step Evaluation and
Triage (SAFE-T)
http://store.samhsa.gov/product/SMA09–4432
Suicide Awareness Voices of Education http://www.save.org
Suicide Prevention International http://www.suicidepreventioninternational.org/
Suicide Prevention Resource Center http://www.sprc.org/
WHO Suicide Prevention http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
82 FOWLER
netic markers. Researchers contribute an impressive list of factors
demonstrating the presence of specific signs or markers that in-
crease the odds of suicide and suicide attempt—Table 2 includes a
sample of static risk factors associated with increase risk. A good
example of the epidemiological research is the cross-national sur-
vey of 84,850 adults assessing sociodemographic and psychiatric
risk factors for suicidal behaviors. Results indicated that being
younger than 25 years of age, female, less educated, unmarried,
and having a mental disorder (mood disorders in high income
countries, and impulse disorders in middle and low income coun-
tries) each imparted a degree of risk for suicide-related behaviors,
with risk increasing with greater psychiatric comorbidity (Nock,
Borges, Bromet et al., 2008). From epidemiologic and social
policy perspectives, this information may be useful in developing
targeted programs for intervention and prevention; yet, distal data
alone are marginally helpful to clinicians—the odds of any of these
factors predicting suicide-related behaviors is relatively low, with
excessively high false-positive rates for each risk factor.
Retrospective and psychological autopsy studies indicate that a
diagnosable mental illness is present in at least 90% of all completed
suicides (Isometsa et al., 1995; Rich, Young, & Fowler, 1986; Con-
well et al., 1996). Clinicians and researchers have long presumed that
some psychiatric disorders convey greater risk for suicide than others.
Harris and Barraclough (1998) found increased suicide risk for all
psychiatric disorders except mental retardation. Suicide mortality
rates were highest for individuals diagnosed with substance abuse and
eating disorders, moderately high rates for mood and personality
disorders, and relatively low rates for anxiety disorders (Harris &
Barraclough, 1998). The difficulty with such evidence is the fact that
the majority of individuals suffering from psychiatric disorders never
make a suicide attempt. Furthermore, over 70% of individuals with a
psychiatric disorder have co-occurring disorders (Kessler et al., 2003),
making prediction based on single diagnoses somewhat spurious.
Efforts to assess comorbidity and severity of psychiatric disor-
ders demonstrate some promising trends. Recent evidence from a
10-year prospective study of suicidal ideation, suicide plans and
attempts revealed that the total number of co-occurring psychiatric
disorders was consistently more predictive of subsequent suicide-
related behaviors than types of disorders (Borges, Angst, Nock,
Ruscio, & Kessler, 2008). A 3-year prospective study revealed that
individuals with comorbid substance abuse disorders and BPD
were more likely to make future suicide attempts (Yen et al.,
2003). Soloff and Fabio (2008) found that comorbid major depres-
sion and BPD, in combination with poor social adjustment was
predictive of suicide attempts at 12-month follow-up. Severity of
personality pathology (defined as meeting criteria for two or more
personality disorders) was correlated with recurrent suicide at-
tempts, but this effect held true only for younger females with
severe personality disorders (Blasco-Fontecilla et al., 2009).
Efforts to predict suicide using finer grain psychiatric variables
such as previous hospitalization, depression, hopelessness, bipolar
disorder, psychotic spectrum disorders, impulsivity, and plans or
thoughts of dying fail to provide sensitive and specific metrics to
function as diagnostic tests (even when combined in risk factor
algorithms). For example, the 5-year prospective study predicting
suicide risk among 4800 psychiatric inpatients found the follow-
ing: During the follow-up period the best algorithm correctly
identify 35 of 63 future suicides; yet, 1206 false positive predic-
tions resulted in a positive prediction value of less than 3%, thus
diminishing the prospect of utilizing the algorithm for diagnostic
purposes (Pokorny, 1983). Focusing on 743 subjects identified as
a high-risk cohort, the results were only slightly improved: the
algorithm correctly identify 21 out of 28 future suicides; yet, 164
false positive predictions resulted in a positive prediction value of
approximately 11 percent.
Assessment of psychological vulnerabilities (an even finer
grained analysis) seemed a logical approach, yet a review of
empirical literature yielded mixed results for the most consistently
studied psychological constructs of impulsivity/aggression, de-
pression, anxiety, hopelessness, and self-consciousness/social dis-
engagement (Conner, Duberstien, Conwell, Seidlitz & Caine,
2001). While impulsivity/aggression has a substantial genetic load-
ing, and shows strong family affinity in those whose family mem-
bers have made suicide attempts, there are a number of factors that
Table 2
Selected Static Risk Factors Associated With Individual Risk for Suicide and Suicide Attempts
Variable Relative predictive strength False-positive risk
Past suicide attempts Strongest consistent predictor for both suicide attempts and completed suicide across
many studies Moderate-high
Co-morbid psychiatric diagnoses Risk increases with greater co-morbidity, especially for substance, mood and personality
disorders High
Single diagnoses Eating disorders, and substance abuse disorders carry the highest risk, mood, and
personality disorders carry moderately high risk, anxiety disorders carry lower risk High
Severity of mental illness Limited studies suggest severity of impairment may be a risk factor beyond the specific
diagnosis High
Algorithms of multiple domains Diagnoses, symptoms, demographic and past history of hospitalization result in
moderate true positive prediction but high false positive High
Psychological vulnerabilities Impulsivity/aggression, depressive symptoms, anxiety, hopelessness, and
self-consciousness/social disengagement increase risk, yet some studies are
inconclusive
High
Genetic markers 5-HTT serotonin gene most studied with moderate association: other candidate genes
vary by study Unknown
Demographic (gender, age, race,
economic status) Males complete more suicides, females attempt more, nonmarried marital status, elderly,
adolescent and young adult age groups, and Caucasian race are all associated with
increase risk
Extremely high
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PRAGMATIC GUIDELINES FOR SUICIDE RISK ASSESSMENT
affect that association, thus reduce the predictive validity of this
single risk factor (Turecki, 2005).
Currently, the strongest risk factor for predicting suicide and
suicide-related behavior is the history of suicide attempts. While
some distinctive clinical and psychological features differentiate
those who attempt suicide from those who die from suicide; most
experts agree that a history of suicide attempt(s) is the greatest risk
factor for future attempts, and death by suicide (Brown, Comtois,
& Linehan, 2002; Cavanagh, Owens, & Johnstone, 1999; Joiner et
al., 2005). Medically serious suicide attempts are strongly associ-
ated with the increased risk of mortality and repeated suicide
attempts: a 5-year follow-up study found that individuals who
made a single suicide attempt were 48 times more likely to die by
suicide than the average person (Beautrais, 2004). In a recent
Finnish epidemiological study of 18,199 cases of suicide attempt,
the risk of repeated attempted suicide within 5 years was 30% and
the risk of death by suicide was 10% (Haukka, Suominen, Par-
tonen, & Lonnqvist, 2008). Suicide attempts confer considerable
future risk, but the risk is far from absolute—calculating false-
positive predictions from Haukka’s data (2008), we find 12,739
false positive predictions for future suicide attempts, and 16,379
false-positive predictions for completed suicide when using past
suicide attempt as the sole predictor.
The promise of genetic markers for predicting suicide and
suicide attempt (including the extensively studied serotonin trans-
porter gene 5-HTTLPR) has yet to be fully realized (Arango,
Huang, Underwood, & Mann, 2003). This may be due to gene-
environment interactions influenced by the cascade of early ad-
verse events on neurological development, and adult response to
stressful life events (Currier & Mann, 2008). The lesson to date is
that no single static risk factor provides an adequate diagnostic tool
for assessing future risk given the unmanageable number of false-
positive predictions.
Proximal Warning Signs
The American Association of Suicidology formed a work group
to address problems associated with detecting suicide risk, recog-
nizing that static, distal risk factors fail to provide adequate diag-
nostic clarity. A research agenda was proposed to focus on near-
term indicators of imminent suicide risk (Rudd, Berman, Joiner et
al., 2006). Whereas risk factors are generally static, warning signs
such as thoughts of suicide, preparatory acts, stressful life events,
and cognitive/affective states are episodic, and therefore may be
more predictive of an imminent suicidal crisis. Table 3 includes a
selection of proximal warning signs associated with increased risk.
Self-report measures and interview strategies for assessing
warning signs of suicidal ideation, intent, and availability of means
have generally failed to produce the anticipated diagnostic clarity
and appear better suited for screening out suicide risk (for exten-
sive reviews of self-report and interview approaches, see Brown,
2002, and Nock, Wedig, Janis, & Deliberto, 2008). Despite the
apparent ubiquity of suicidal ideation before suicide attempts, the
relationship is complicated—most individuals contemplating sui-
cide do so for extended periods without following through on the
thoughts. A closer examination of the 10-year prospective study
cited earlier (Borges, Angst, Nock, Ruscio, & Kessler, 2008)
highlights the limited predictive utility of suicidal ideation: Using
data from two National Comorbidity Surveys, 5001 subjects were
interviewed regarding suicidal ideation, suicidal plans, gestures,
and serious attempts. Suicide ideation was predictive of future
suicidal ideation, but was negatively related to risk of future
suicide attempt in the absence of a past plan or attempt. Further-
more, past suicide plans predicted the likelihood of future suicidal
ideation and suicide plans, but not future attempts—only a history
of prior suicide attempt was significantly and positively related to
future suicide attempt (Borges, Angst, Nock, Ruscio, & Kessler,
2008). The results of a second study are chilling: a prospective
study of 76 psychiatric inpatients found that 78% of individuals
who completed suicide had denied suicidal ideation or intent
during their last human contact before their death (Busch, Fawcett,
& Jacobs, 2003).
Increasingly, researchers are questioning the reliance on self-
report from suicidal individuals who may be motivated to dissim-
ulate, are unable to accurately assess their emotional states, or are
Table 3
Selected Warning Signs Associated With Individual Risk for Suicide and Suicide Attempts
Variable Relative predictive strength False-positive risk
Suicidal ideation/plan Suicidal ideation is assumed to be present in the majority of suicide attempts
and completed suicides; however, suicide attempters frequently deny
suicidal ideation prior to attempt, and many individuals have suicidal
thoughts without making attempts
High
Stressful life events Stressful life events involving interpersonal loss, humiliation, betrayal, and/
or involve legal issues are associated with increase risk, but this effect
tends to be true for those with genetic and psychological vulnerabilities
Moderate-high
Implicit measures assessing
suicide-related outcomes Implicit cognitive and affective measures, as well as interview approaches
focusing on intense affect states are predictive of later suicide related
behaviors with relatively low false positive prediction. Limited studies and
small samples
Low-moderate
Gene X stressful life events Promising results linking 5HTTPLR-SS and number of stressful life events
to later onset of depression and suicide attempt. More studies needed Unknown
Posthospitalization transition Suicide rates spike immediately following discharge from psychiatric
hospitalization, and remain high during the first week and first month
following discharge. Patients who make unilateral decisions to discharge
are at greater risk
Moderate-high
84 FOWLER
poor prognosticators of future risk (Hendin, Maltsberger & Szanto,
2007; Nock & Banaji, 2007). Several research teams investigating
short-term risk circumvent problems associated with self-report
bias by developing computer-based measures that assess implicit
psychological processes (Cha, Najmi, Park, Finn, & Nock, 2010;
Nock & Benaji, 2007), use interview strategies focusing on current
affective states while intentionally avoiding reference to suicide
(Hendin et al., 2007; Hendin, Al Jurdi, Houck, Haas, & Turner,
2010), or extract dimensions of cognition and affective functioning
using the Rorschach Inkblot Method (Affra, 1982; Exner & Wiley,
1977; Fowler, Piers, Hilsenroth, Holdwick, & Padawer, 2001;
Fowler, Hilsenroth & Piers, 2001; Fowler et al., under review;
Silberg & Armstrong, 1992). These indirect measures show con-
siderable predictive validity with uncharacteristically low levels of
false-positive prediction. Of considerable importance is the fact
that two implicit measures (Cha et al., 2010; Fowler et al., in press)
demonstrated incremental validity over and above a history of past
suicide attempt.
Stressful life events, particularly those involving loss or threat to
the stability of interpersonal relationships are associated with
suicide risk (Heikkinen et al., 1997; Paykel, Prusoff, & Myers,
1975). More recently, researchers from the Collaborative Longi-
tudinal Personality Disorders Study examined the link between
personality disorders and specific negative life events in the month
preceding a suicide attempt—those who made attempts were more
likely to have experienced a negative stressful life event related to
love and marriage problems, or legal troubles such as incarceration
(Yen et al., 2005). This held true even after controlling for baseline
diagnoses of BPD, major depressive disorders, substance use dis-
orders, and history of childhood sexual abuse.
Psychiatric hospitalization may function as a stressful life event,
despite the intended purpose of decreasing suicide risk. Numerous
studies demonstrate that risk of future suicide is greater shortly
after admission and discharge (Appleby et al., 1999; Goldacre,
Seagroatt, & Hawton, 1993; Rossau & Mortensen, 1997). While
hospitalization is likely a proxy for sustained suicide crisis, one
study sheds light on the risks involved in admissions that are too
brief—using Danish national registries, Qin and Nordentoft
(2005) examined the temporal relationships among hospitalization
and suicide risk, discovering that suicide risk spikes immediately
after admission and 1-week postdischarge, and the risk of suicide
is greatest for individuals with hospital stays less than the national
median (estimated at 17 days). A second study (Hunt et al., 2009)
found that the first day, first week, and first month postdischarge
were the highest risk periods, and were strongly associated with
patient-initiated discharge and failure to follow-up with postdis-
charge care, but not duration of hospitalization. This suggests that
patients discharging from hospital against the recommendations of
the attending physician, and without adequate planning or
follow-up care may be motivated to flee the protective constraints
of a hospital unit.
Diathesis-Stress Models of Risk
There is growing consensus among researchers that suicide risk
is best conceptualized as a complex diathesis-stress phenomenon.
Most theories posit an underlying genetic vulnerability that is
triggered by early adverse events, resulting in impaired develop-
ment and function of neurobiological systems regulating behavior,
affect, and cognitive function. Impairments in stress response
systems may then be overwhelmed (during adolescence and adult-
hood) in response to episodic negative life events, increasing the
likelihood of triggering a suicidal crisis. Thus, underlying genetic
and psychological vulnerabilities are assumed to be triggered by
environmental stressors, increasing likelihood of negative out-
comes including suicidal behavior (Currier & Mann, 2008; Mann,
Waternaux, Haas, & Malone, 1999; Turecki, 2005; Rudd, 2006).
Studies generally support diathesis-stress models for predicting
suicide risk—interactions between early adverse events and cur-
rent impulsivity (Brodsky et al., 2001) loneliness and recent stress-
ful life events (Chang, Sanna, Hirsch, & Jeglic, 2010), and level of
psychopathology and recent stressful life events in alcoholics
(Conner, Beautrais & Conwell, 2003) confer increase risk of
suicide-related behaviors. Diathesis-stress models appear to impart
added risk for suicide above and beyond assessment of these
factors in isolation. The one exception is individuals who have
made multiple suicide attempts in which stressful life events did
not correlate with intensity of suicide crisis (Joiner & Rudd, 2000).
Multiple suicide attempts may lead to habituation by reducing
normal barriers such as pain, fear of death, and negative social
consequences (Joiner, 2005).
An intriguing gene-environment study demonstrated a link be-
tween the serotonin transporter functional promoter polymorphism
(5-HTTLPR), recent stressful life events, and suicide-related be-
havior (Caspi et al., 2003). In this study, a combination of four or
more stressful life events was associated with increased suicidal
ideation and attempts for individuals with two copies of the short
form of the 5-HTTLPR gene, but had minimal effect on those with
two long forms of the gene.
Protective Factors
Pathological risk factors dominate suicide research, and yet
protective factors that impart a degree of resilience against suicidal
behaviors are crucial because the interplay of risk and protective
factors may ultimately determine the outcome for individuals
(Goldsmith et al., 2002). It is curious why protective factors were
not more salient in earlier studies because clinicians routinely
work to enhance modifiable protective factors when treating sui-
cidal patients. With the rise of the positive psychology movement
and greater emphasis on resilience as a viable psychological con-
struct, protective factors are increasingly included in studies, but
the measurement and mechanisms of specific protective factors
remain unclear. Some leading protective factors are discussed in
the following section (Table 4).
The ability to maintain a cognitive set regarding reasons for
living appears to function as a protective factor (Malone et al.,
2000; Linehan, Goodstein, Nielsen, & Chiles, 1983). For example,
in a cross-sectional study, depressed patients who had not previ-
ously attempted suicide were found to have expressed more feel-
ings of responsibility toward their children and families, feared
social disapproval, had more moral objections to suicide, greater
survival and coping skills, as well as greater fear of suicide than a
matched cohort of depressed patients who had previously at-
tempted suicide (Malone et al., 2000). In a 2-year prospective
study, reasons for living were a protective factor against future
suicide attempts among depressed female inpatients, but not for
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PRAGMATIC GUIDELINES FOR SUICIDE RISK ASSESSMENT
their male counterparts (Lizardi et al., 2007). Healthy and well-
developed coping skills may provide a buffer against stressful life
events, decreasing the likelihood of suicidal behavior (Josepho &
Plutchik, 1994).
Among protective factors, moral objections and strength of
religious convictions appear protective. In general, individuals are
less likely to act on suicidal thoughts when they hold strong
religious convictions and a belief that suicide is morally incom-
patible with belief (APA, 2003; Maris, 1981; Neeleman, Wessley
& Lewis, 1998). Religious and spiritual beliefs and techniques may
decrease suicide risk by providing coping strategies and a sense of
hope and purpose (APA, 2003). Involvement in religious organiza-
tions may also increase resiliency by enhancing more stable support-
ive social networks (Pescosolido & Georgianna, 1989).
Marriage imparts a degree of protection against suicide
(Kposowa, 2000; Kreitman, 1988; Smith, Mercy, & Conn, 1988),
yet the presence of a high-conflict or violent marriage can function
as a risk factor (APA, 2003). Pregnancy is also a time of signifi-
cantly reduced suicide risk for healthy women (Harris & Barra-
clough, 1998); however, risk is significantly greater for pregnant
teenagers, pregnant women of lower socioeconomic status, and
women who are psychiatrically hospitalized postpartum (Appleby,
Mortensen, & Faragher, 1998; Yonkers et al., 2001). For women,
the presence of children in the home may provide an additional
protective effect (Marzuk et al., 1997; Qin & Mortensen, 2003;
Nock, Borges, Bromet et al., 2008). Curiously, while having
children in the home is a protective factor against suicide and
suicide attempts, it increases the likelihood of suicidal ideation,
suggestive of marked stress involved in child rearing (Nock,
Borges, Bromet et al., 2008).
With national focus of bullying and adolescent suicide, consid-
erable research interest is now trained on the social environment
and social supports (or lack thereof) for teens. In a reanalysis of a
national survey of adolescents, Winfree and Jiang (2010) found
that feeling safe at school was one of the most consistent protective
factors against suicidal ideation and suicide attempts. Strong fam-
ily attachment when coupled with a cohesive neighborhood net-
work also reduces the risk of adolescent suicide attempts (Maimon,
Browning, & Brooks-Gunn, 2010).
One of the prime, modifiable protective factors is the experience
of positive supportive relationships between patient and clinician
(APA, 2003). Clinicians of all theoretical persuasions work to
establish and enhance a positive therapeutic relationship, and many
focus significant attention on improving the quality of communi-
cation in marital and family relationships through individual, cou-
ples, and family therapy. A number of randomized clinical trials
demonstrate the efficacy of interventions providing a caring and
concerned social support through letters, phone contacts, or brief
interviews in reducing suicide-related behaviors (Motto & Bos-
trom, 2001; Fleischmann et al., 2008; Guthrie et al., 2001). The
collaborative assessment and management of suicidality interven-
tion (CAMS; Jobes et al., 1998; Jobes, 2011) is a suicide-specific
manualized treatment to help patients and clinicians to establish
and maintain a therapeutic alliance while the pair works to under-
stand the meanings and functions of suicidal ideation. Open trials
of CAMS demonstrate decreased suicidality among outpatients
(Jobes et al., 2005) and psychiatric inpatients (Ellis et al., 2011).
Thus numerous studies identify therapeutic, family, and social
relationships as protective, but the quality and stability of relation-
ship and social structures appear to determine the valence as a
protective or risk factor.
Pragmatic Approaches to Risk Assessment
When initiating treatment with high-risk patients, it is best to
negotiate a collaborative treatment approach to suicidal thoughts
and behaviors that includes, (1) a clear plan for de-escalating a
suicidal crisis, (2) negotiation of the mutual and individual respon-
sibilities of clinician and patient in establishing and maintaining
the patient’s safety, and (3) agreement to explore the precipitants
and meaning of the crisis once it has past (Jobes, 2011). The
CAMS approach is one systematic method to help patients and
Table 4
Selected Protective Factors Associated With Individual Risk for Suicide and Suicide Attempts
Variable Relative predictive strength
Religious affiliation/beliefs Strength of religious conviction, social supports, and spiritual practices serving as coping strategies all serve as
protective factors
Reasons for living Incorporates aspects of social and religious/moral protective factors into a single scale. Demonstrates protective
factor in cross sectional studies of adult and adolescents, but was only protective for females in a
prospective study of depressed inpatients
Marriage Protective factor except in the presence of a high-conflict or violent relationship when marriage becomes a risk
factor
Children in the home Protective factor except in the cases of post-partum mood or psychotic disorders, teen pregnancy, and extreme
economic hardships. Children in the home increase risk of suicidal ideation, suggesting heightened emotional
strain associated with childrearing
Supportive social networks Religious organizations, close familial ties, supportive school and neighborhood environments have been linked
to decreased risk of suicide attempts
Therapeutic contacts Randomized clinical trials of psychosocial treatments of Borderline Personality disorder reduce suicide
attempts and hospitalizations. The Collaborative Assessment and Management of Suicidality intervention
reduces suicidality in open trials
Psychotropic medications Randomized clinical trials of lithium prophylaxis for mood disorders and clozapine for psychotic disorders
reduce suicide attempts
Brief supportive contacts Randomized clinical trials demonstrate reduced occurrence of suicide attempts using outreach via
communicating caring and concern remotely or in-home psychodynamic consultations
86 FOWLER
clinicians address these issues and to establish and maintain a thera-
peutic alliance while working to understand the meanings and func-
tions of suicidal ideation. The centrality of collaboration and negoti-
ation within the context of the therapeutic alliance helps clinician and
patient avoid power struggles, rescue fantasies, pathological depen-
dency, and false compliance. If suicidality emerges in course of
treatment, CAMS or other treatment heuristics can be implemented,
but the immediate issue of assessment and intervention remains.
Given the fact that the accuracy of suicide risk assessment is less
than perfect, what is a clinician to do when faced with assessing
suicidal patients? Knowing that patients frequently deny suicidal
thoughts before suicide attempt and death, clinicians should re-
main appropriately circumspect regarding declarations of safety
when a patient recently expressed suicidal ideation, feelings of
hopeless, desperation, and/or affective flooding. This does not
mean we should adopt a suspicious or adversarial stance—on the
contrary, curiosity, concern, and calm acceptance of the patient’s
emotional and cognitive states may serve to enhance the therapeu-
tic alliance, encourage the patient to directly explore her or his
current distress, and aid in the accurate evaluation of current
functioning. In this way, a positive and cooperative therapeutic
relationship can serve as ballast against suicidal urges (APA,
2003). At the same time, the clinician must be mindful of personal
reactions that can lead to nontherapeutic (re)actions such as con-
veying an adversarial or hostile tone, taking on a savior role,
blurring professional boundaries, and avoidance or overcompen-
sation for negative feelings that emerge (Hendin, 1991; Malts-
berger & Buie, 1980).
Before conducting a formal suicide assessment, clinicians
should conduct an introspective review of recent stressful life
events facing the patient, including recent ruptures in the thera-
peutic alliance, and disturbances in social relationships (Truscott,
Evans, & Knish, 1999). Maintaining a therapeutic stance of curi-
osity and concern (while simultaneously remaining open to the
possibility that an alliance rupture may be a precipitant to the
crisis) is difficult to sustain when anxieties are running high;
however, communicating genuine curiosity and concern about the
causes for their unbearable suffering is critical.
Although risk factors and measures rarely provide consistent
evidence of efficient diagnostic tests, experts generally agree that
a multidimensional assessment incorporating the best known risk
and protective factors is the most reasonable course of action
(APA, 2003; Brown, 2002; Goldsmith et al., 2002; Nock, Wedig,
Janis et al., 2008; Rudd et al., 2006; Oquendo et al., 2003). While
several systems exist, few provide guidelines for summarizing
findings, provide heuristics for benchmarking risk, and fewer
suggest interventions when heightened risk is the outcome. A
notable exception is the Substance Abuse and Mental Health
Services Administration sponsored Suicide Assessment Five-step
Evaluation and Triage (SAFE-T; go to: http://store.samhsa.gov/
product/SMA09-4432 to download or order a free pocket guide).
Derived from data and recommendations from the American Psy-
chiatric Association Practice Guidelines (2003), the SAFE-T is a
comprehensive, practical, and efficient assessment strategy that
partially overcomes the limitations of single risk factors by includ-
ing recent stressful life events and current patterns of ideation and
motivation for suicide, while providing the necessary counter-
weight of protective factors that may mitigate the likelihood of
suicidal behavior in some individuals. Clinicians working with
high-risk individuals are guided through the following steps: (1)
identifying relevant risk factors (noting those that are modifiable
and therefore targeted for treatment), (2) identifying protective
factors, (3) conducting a suicide inquiry including current suicidal
thoughts, plans, behavior, and intent, (4) determining level of risk
and select interventions to reduce risk, and (5) documenting the
assessment of risk, the rationale for the chosen interventions, and
follow-up after assessment and interventions.
Assessments are conducted at first contact and whenever the
clinician anticipates that risk may be elevated. Clinicians assess
static risk factors such as history of abuse, history of suicide
attempts, diagnostic risk factors, family history of suicide attempts,
as well as presenting symptoms of anhedonia, impulsivity, hope-
lessness, insomnia, and command hallucinations. Warning signs
are incorporated into the assessment including potentially trigger-
ing events of loss, humiliation, current family chaos, and spikes in
alcohol abuse and intoxication. Protective factors such as internal
coping resources, religious beliefs, and external reasons for living
(responsibility for children, positive therapeutic relationships, and
social supports) provide ballast for risk factors, but are considered
minimally influential when strong risk factors and triggering
events are present. Following a thorough evaluation of risk and
protective factors, clinicians should conduct a sensitive inquiry into
current suicidal ideation, plan, behaviors (such as rehearsals and
preparation), taking pains to express concern and attending to the
alliance in order to communicate caring and maximize the likelihood
of accurate reports. Determining relative risk must rely on the clini-
cian’s judgment in weighing the combination of risk and protective
factors, assessing the patient’s social supports, the state of the thera-
peutic alliance, and the patient’s sense of desperation.
Once the assessment is complete, clinicians can benchmark the
results against the SAFE-T guidelines for relative risk (high,
moderate, low). Determining interventions (including medication
consult, providing additional psychosocial supports, developing a
crisis plan, providing emergency phone number/crisis hotline num-
bers, and hospitalization) should be negotiated, if possible, with
the patient as a partner in the decision making process. The risk
level and rationale for the treatment plan to address and reduce
current risk and any plans for follow-up assessments should be
clearly and concisely documented. Resources for documentation of
risk are available at: http://www.rmf.harvard.edu/files/documents/
suicideAs.pdf.
When clinicians face a potential suicide crisis, they are multi-
tasking and are usually in a state of heightened alert and anxiety.
Under such stressful circumstances, it is easy to get swept up in
personal emotional reactions and lose sight of the patient’s suffer-
ing and their efforts to communicate distress. Conducting the
SAFE-T or other multidimensional assessments requires not only
thorough evaluative skills, it requires the clinician’s skill in com-
municating caring and concern, active curiosity about the precip-
itants, and the role of enhancing the alliance, or repairing alliance
ruptures in de-escalating crises.
Conclusions
Diagnostic tests for accurately predicting individual level risk
remain elusive; yet, several research developments hold consider-
able promise, such as combining measures from multiple domains
and using implicit measures of affect and cognition that circum-
87
PRAGMATIC GUIDELINES FOR SUICIDE RISK ASSESSMENT
vent some of the limitations of self-report approaches. Researchers
and clinicians will continue to search for markers that may hold the
key for developing a truly sensitive and accurate diagnostic test or
panel that can alert clinicians to ongoing vulnerability and immi-
nent heightened risk.
Throughout this review emphasis has been placed on exceed-
ingly high false-positive rates as a limiting step to individual
patient suicide risk assessment, and many suicide experts imply
that false positive predictions are the unfortunate cost of such
assessments. While patient safety is the prime objective, there are
unanticipated consequences to suspending another person’s basic
civil rights when hospitalizing patients (especially when based on
inaccurate data from suicide assessments). Unnecessary hospital-
ization can lead to a sense of betrayal, alliance ruptures, unilateral
termination of treatment, and conceivably, an inadvertent stressful
life event that increases future suicide risk.
Given these high stakes, clinicians are advised to negotiate how
the therapeutic pair will deal with suicidal ideation, preferably well
in advance of a crisis. Discussing the possible interventions in the
event of a suicide crisis, and negotiating a strategy may help the
patient take some authority and ownership over decisions, and may
ultimately mitigate the interventions being experienced as a be-
trayal. When assessment and exploration of meaning are built into
the treatment frame clinician and patient have a greater chance of
avoiding or circumventing power struggles and are in a better
position to repair alliance ruptures. Focusing on the therapeutic
relationship, and using the therapeutic alliance as a platform for
exploring the causes and meaning of suicidal thoughts, clinician
and patient may increase the likelihood of working together to
avert suicide-related outcomes.
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Received September 9, 2011
Accepted September 16, 2011
90 FOWLER
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